The research, published in PLOS Global Public Health, was led by Annet Mary Namusisi and colleagues at the Uganda Public Health Fellowship Program and partner institutions. In March 2025, just as the national campaign was getting underway, the team interviewed 292 caregivers attending the Maternal and Child Health unit of Masaka Regional Referral Hospital, a busy facility serving a region where malaria transmission is intense and year-round. The timing was deliberate: by capturing attitudes at the very start of vaccine introduction, the investigators could measure baseline willingness before mass messaging and early rollout experience had a chance to shape opinion, providing a snapshot of the informational landscape into which the R21 vaccine was being launched.

Methodologically, the study was designed to avoid the biases that often plague clinic-based surveys. Each day, researchers generated complete lists of caretakers attending the unit to serve as sampling frames, then used systematic sampling with a calculated interval to select participants, ensuring that every caregiver had a known chance of inclusion rather than simply interviewing whoever arrived first. The questionnaire assessed whether caregivers were willing to have their children vaccinated with the malaria vaccine, and the team used modified Poisson regression to identify factors statistically associated with willingness, an approach well suited to common outcomes in cross-sectional data because it yields adjusted prevalence ratios that are easier to interpret than odds ratios when the outcome is not rare.

The headline finding was strikingly positive. Of the 292 caretakers interviewed, 250, or 86 percent, were female, reflecting the reality that mothers overwhelmingly accompany children to health facilities in Uganda. Among all respondents, 249, or 85 percent, said they were willing to have their children receive the malaria vaccine. Perhaps most telling, the majority of caretakers had never even heard of the malaria vaccine before the interview, yet expressed readiness to accept it once oriented. This combination of low awareness and high openness suggests that the primary challenge in Uganda is not entrenched opposition to the vaccine but an information gap, one that health authorities can close through deliberate, well-targeted communication.

Beneath the aggregate enthusiasm, however, the regression analysis uncovered a set of factors that significantly raised or lowered willingness, and these carry important lessons for the rollout. On the positive side, caregivers who had received intermittent preventive treatment in pregnancy, known as IPTp, were far more willing to vaccinate their children, with an adjusted prevalence ratio of 6.2 and a 95 percent confidence interval of 1.6 to 23. IPTp involves administering antimalarial medication to pregnant women at routine antenatal visits to protect both mother and fetus, so a history of receiving it signals sustained engagement with antenatal care and familiarity with the idea of using antimalarial interventions preventively. Women who had already benefited from one malaria prevention strategy during pregnancy appear primed to embrace another for their children.

Even more powerful was trust in vaccine safety, which was associated with a thirteenfold increase in willingness, with an adjusted prevalence ratio of 13 and a confidence interval of 4.0 to 43. This finding underscores a truth well documented in immunization research worldwide: confidence in a vaccine’s safety profile is the single strongest driver of acceptance, outweighing general awareness or even perceived benefit. For a brand-new vaccine like R21, which many caregivers had never heard of before the study, safety perceptions are being formed right now, in real time, through conversations with health workers, community leaders and fellow parents. The authors argue that this makes safety-focused messaging, rather than generic awareness campaigns, the most effective communication strategy for the rollout.

Three factors were associated with reduced willingness, and each tells a distinct story. Caregivers who had previously experienced adverse events following immunization, known as AEFIs, with their children were dramatically less willing to accept the malaria vaccine, with an adjusted prevalence ratio of 0.2 and a confidence interval of 0.05 to 0.5. This is a rational response from the caregiver’s perspective: a parent whose child developed fever, swelling or another reaction after a routine vaccine naturally worries about adding a new four-dose series to the schedule. The implication is not that these families are lost causes, but that health workers need to be specifically prepared to discuss AEFI history, explain what side effects the malaria vaccine can cause and how they are monitored, and reassure parents that reactions are typically mild and transient.

Household decision-making dynamics also mattered. When someone other than the child’s biological parent, such as a grandparent or other relative, was the main decision maker for the child’s health, willingness dropped sharply, with an adjusted prevalence ratio of 0.2 and a confidence interval of 0.04 to 0.9. In many Ugandan households, particularly in extended-family arrangements, fathers, mothers-in-law or senior relatives hold final authority over children’s medical care even when mothers do the actual clinic visits. This means that a mother’s positive attitude at the health facility may not translate into vaccination if she must first persuade a decision maker who was never exposed to the health worker’s counseling. Reaching these influential relatives, whether through community dialogues, male engagement strategies or household-level communication, could be essential for converting willingness into actual uptake.

Surprisingly, caregivers with tertiary education were also less willing to vaccinate, with an adjusted prevalence ratio of 0.14 and a confidence interval of 0.04 to 0.6. This inverts the pattern often seen in vaccine acceptance studies, where higher education typically correlates with greater uptake. The authors do not overinterpret this finding, but it is consistent with a growing international literature showing that highly educated parents in some settings express more vaccine hesitancy, sometimes because they consume more diverse information sources, including online content that questions vaccine safety, or because they feel more entitled to question medical authority. Whatever the mechanism, the finding warns Ugandan program planners against assuming that educated urban families will be the easiest to reach, and suggests that communication strategies must be tailored across the education spectrum rather than designed only for those with limited schooling.

The study’s recommendations flow directly from its statistical findings. First, the authors propose delivering malaria vaccine information through antenatal care services, capitalizing on the strong association between IPTp receipt and willingness by embedding vaccine education in the very visits where pregnant women already receive malaria prevention and build trust with health workers. Second, they call for preparing health workers to address AEFI histories and vaccine-safety concerns directly, equipping frontline staff with the facts and counseling skills to convert hesitant parents rather than simply recording refusals. Third, and perhaps most strategically, they recommend prioritizing safety-focused messaging over general awareness messaging, since trust in safety was the strongest single predictor of acceptance while mere awareness left most caregivers unmoved. With Uganda third in the world for malaria cases and children under five bearing the deadliest toll of severe disease, the R21 vaccine represents a genuine turning point, and this early evidence from Masaka suggests that the demand is largely there, waiting to be secured through communication that respects caregivers’ real concerns about safety, family dynamics and personal experience.

Subject of Research: Caregiver willingness and factors influencing uptake of the R21 malaria vaccine among children under five in Uganda

Article Title: Caregivers’ willingness and factors influencing uptake of the malaria vaccine among under-five children at Masaka Regional Referral Hospital, Uganda

Article References: Namusisi, A. M., Migisha, R., Kizza, D., Kwesiga, B., Bulage, L., Tusuubira, V., Nakayiza, L. M., Tageya, S., Nsubuga, F., Atugonza, R., Baganizi, M., & Ario, A. R. (2026). Caregivers’ willingness and factors influencing uptake of the malaria vaccine among under-five children at Masaka Regional Referral Hospital, Uganda. PLOS Global Public Health, 6(10), e0005764. https://doi.org/10.1371/journal.pgph.0005764

Image Credits: AI Generated

DOI: 10.1371/journal.pgph.0005764

Keywords: malaria vaccine, R21 vaccine, Uganda, vaccine hesitancy, caregivers, children under five, vaccine safety, IPTp, adverse events following immunization, Masaka Regional Referral Hospital, PLOS Global Public Health, malaria prevention

The research team, led by Augustino Hellar of Prime Health Initiative Tanzania together with collaborators from the Tanzanian Ministry of Health, Jhpiego, and regional authorities, took advantage of an unusual opportunity: a complete census of antenatal care delivery rather than a sample. Between January 2023 and August 2024, all 5,936 pregnant women who enrolled in group antenatal care, often abbreviated G-ANC, across six public health facilities in Geita Region were included in the analysis. These facilities spanned the typical tiers of the Tanzanian health system, comprising two dispensaries, two health centers, and two district hospitals. The women were organized into 149 group cohorts, a model in which small groups of expectant mothers attend antenatal sessions together, combining clinical assessment with peer learning and discussion.

Group antenatal care has attracted growing interest across low- and middle-income countries because it promises to improve both the experience and the quality of care. Instead of the traditional one-on-one consultation, women in a G-ANC cohort meet repeatedly with the same facilitators and peers, which proponents argue increases satisfaction, knowledge retention, and retention in care. Tanzania’s Mlinde Mama Project embedded this model into routine government services rather than running it as a standalone research intervention, which is precisely what makes the new findings valuable. When a model moves from a carefully resourced pilot into the everyday machinery of a health system, its performance becomes a test of the system itself.

The headline numbers from the analysis were genuinely encouraging. Coverage of four or more antenatal care visits ranged from 90.2 to 95.0 percent across the six facilities, facility-based delivery ranged from 94.1 to 97.7 percent, and malaria testing reached 91.5 to 95.5 percent of enrolled women. Blood pressure monitoring was recorded for every single participant at every facility, a perfect 100 percent. These figures suggest that the group care model, when integrated into routine services, can achieve and sustain very high levels of service utilization, confirming that the attendance half of the maternal health equation is being solved at these sites.

But the picture changed sharply when the researchers looked beyond utilization to what clinicians actually delivered during those visits. Coverage of three or more doses of intermittent preventive treatment for malaria in pregnancy, the standard sulfadoxine-pyrimethamine regimen known as IPTp3+, ranged from 60.1 percent at the lowest-performing facility to 86.3 percent at the best, a gap of more than 26 percentage points for an intervention that protects both mother and fetus from a potentially devastating infection. Iron and folate supplementation, a cornerstone of prenatal nutrition, ranged from 75.0 to 92.7 percent. Most striking were the diagnostic services: HIV and syphilis testing coverage spanned from 59.9 to 95.0 percent, and urine testing, which screens for conditions such as pre-eclampsia risk and urinary tract infections, ranged from a troubling 30.1 percent to 62.7 percent. In other words, at one facility fewer than one in three women received a urine test that guidelines recommend for all.

To synthesize these differences, the team calculated a composite facility performance score as the mean coverage across nine selected indicators. The scores ranged from 80.1 to 91.9 percent, with Bwanga Health Center ranking highest and Butengorumasa Dispensary lowest. Health centers demonstrated the strongest overall performance across most indicators, outperforming both the smaller dispensaries and, in several respects, the district hospitals. Statistical testing using Pearson’s chi-square confirmed that the variation in coverage of the nine composite indicators across facilities was significant, with p-values below 0.05, meaning the differences were unlikely to be products of chance.

The pattern of variation carries important technical implications for how maternal health programs are monitored. Attendance-based metrics, such as the proportion of women completing four antenatal visits, are the traditional currency of maternal health surveillance because they are easy to measure and track. Yet the Geita data demonstrate that these metrics can mask profound differences in effective coverage, the proportion of the population actually receiving the interventions they need. A woman can attend every scheduled session and still leave without syphilis screening, without her full course of malaria prophylaxis, or without anemia assessment. Effective coverage, a concept increasingly emphasized by global health measurement initiatives, requires looking at what happens inside the consultation, not merely whether the consultation occurred.

Why would facilities within the same region, operating under the same national guidelines and implementing the same group care model, diverge so widely? The study did not formally test explanatory mechanisms, but the structure of the findings offers clues. Interventions requiring reliable supply chains, such as sulfadoxine-pyrimethamine for malaria prophylaxis and rapid diagnostic tests for HIV and syphilis, showed the largest gaps, while interventions depending only on clinical skill and a blood pressure cuff achieved universal coverage. This suggests that stock-outs, laboratory capacity, and equipment availability, rather than staff knowledge or patient demand, may drive much of the variation. Facility tier also mattered, with health centers occupying a sweet spot of sufficient resources without the patient volumes and staffing pressures that may strain larger district hospitals.

The authors argue that their findings support a shift in how antenatal programs are managed: facility-level performance monitoring should track the content of care alongside attendance, supported by supportive supervision and continuous quality improvement cycles. Because the analysis drew on routinely collected implementation data rather than a bespoke research dataset, the approach is inherently scalable; health managers could, in principle, reproduce these composite scorecards using existing health management information systems. The study also carries a caution about interpretation, since it reflects a single region and a program supported by external funding from the Gates Foundation, and the authors note that the published version is an early-release article subject to further editorial refinement.

For the global maternal health community, the message from Geita is both sobering and actionable. Tanzania has made substantial progress in getting pregnant women into contact with the health system, and the near-universal blood pressure monitoring and delivery coverage documented here show that the system can perform at scale. The unfinished agenda is consistency: ensuring that the woman at the lowest-performing dispensary receives the same malaria prophylaxis, the same syphilis test, and the same urine screening as the woman at the best-performing health center. Closing that gap does not require new medical discoveries, only the disciplined application of measurement, supervision, and supply chain management to interventions that are already proven, affordable, and sitting on national guidelines waiting to be delivered.

Subject of Research: Facility-level variation in the delivery of essential antenatal care interventions during routine group antenatal care implementation in Tanzania

Article Title: Beyond attendance: facility-level variations in the delivery of essential antenatal care interventions during routine group antenatal care implementation in Tanzania: a secondary analysis

Article References: Beyond attendance: facility-level variations in the delivery of essential antenatal care interventions during routine group antenatal care implementation in Tanzania: a secondary analysis. (n.d.). https://doi.org/10.1186/s12913-026-15769-4

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15769-4

Keywords: antenatal care, group antenatal care, Tanzania, maternal health, effective coverage, health facility performance, quality of care, malaria in pregnancy, IPTp, health services research, implementation science, Geita Region